Since the state passed a health reform law in 2006 mandating health insurance coverage, demand for internal medicine and family practice physicians to manage office-based patient care has soared.

At the same time, the supply of primary care physicians — particularly those seeing adults — has shrunk as a result of relatively lower pay and high medical school debt, heavy schedules and attractive options in other types of care.

The Massachusetts Medical Society released last week its "2013 MMS Patient Access to Care Study," which documented trends by county in how long it takes for a new patient to get an appointment for common services in a range of specialties. The survey was done by telephone interviews with 1,137 physicians statewide, with a minimum of 10 interviews per specialty, per county.

Statewide, the study found stable or shorter wait times for new patient appointments in all specialties except internal medicine, orthopedic surgery and pediatrics. However, there have been year-to-year fluctuations.

Dr. Kelleher said the survey's measurement of how long it took to get the first available appointment for a new patient wasn't the industry standard, which is to measure time until the third available appointment. The first or second available appointment could pick up last-minute cancellations and show a lower wait time than the true average, he said.

While the study's average wait time for an internal medicine appointment decreased to 26 days in 2013 from 37 days in 2012, Dr. Kelleher said, "From our perspective, we're not seeing that Worcester County has easy access to adult primary care."

Group practices in Worcester County are taking access seriously, as the demand for care continues to grow with an aging population and more people having health insurance.

Reliant has met standards for recognition by the National Committee on Quality Assurance as a Level 3 "patient-centered medical home," using a team-based approach that focuses on coordination, communication and timely access to care.

Not only has the medical group hired seven more advanced-practice clinicians, such as nurse practitioners and physician assistants, who provide primary care under a physician's supervision, but it also employs nurses and medical assistants in innovative ways.

For instance, nurses do follow-up checks on patients with high blood pressure, high-risk diabetes, or who are taking blood thinners.

Medical assistants work with Reliant's database to contact high-risk patients with chronic diseases, including depression, who may be overdue for an appointment or need a check-in on medication.

Dr. Kelleher said: "That's a much expanded role. We call it the health coach model. Some would call them population managers."

Physicians' time is also leveraged through group visits lasting an hour and a half, offered to patients with common chronic diseases such as diabetes, high blood pressure and high cholesterol.

"There are a surprising number of patients who enjoy it (groups)," Dr. Kelleher said. "Patients learn from each other. They offer each other tips."

Patients can get quick, personal medical information on line, via their electronic MyChart system. More than a third of patients use this option to enter information electronically, which is then evaluated by a nurse, who advises the patient on care.

Urgent care and ReadyMED walk-in clinics are offered at some Reliant sites to provide prompt access, as well.

Dr. Charles Cavagnaro, an internal medicine physician and interim president of UMass Memorial Medical Center, said health care is in an era of change that is still being sorted out.

"It's going to be a much more on-demand situation," he said. "The focus is going to shift to population management.

"Even so, the future is about more primary care docs. And they're a tougher and tougher breed to recruit."

Dr. Cavagnaro said that when he graduated 30 years ago, half his medical class went into primary care. Now it's only one or two from University of Massachusetts Medical School's internal medicine program, barely 5 to 10 percent.

Internal medicine physicians now opt to work as hospitalists, seeing patients on a regular schedule in the hospital rather than the office.

And by 2015, under the federal Affordable Care Act, physicians will be required to use electronic medical records. While the move to integrated technology is meant to improve coordination of care, the investment for some aging office-based physicians is too much and some have decided to retire early.

To improve access at UMass Memorial, the medical center instituted this year what it calls "the access promise" at 70 percent of its ambulatory clinics. The clinics see 80 percent of patient visits, including for specialties such as OB-GYN, cardiology, surgery, gastroenterology and pediatrics.

Under the access promise, clinics commit to getting a patient an appointment within 48 hours, although the patient might not be able to request a specific physician.

Jay Cyr, senior vice president of operations, said, "Initially, people were really surprised (when they were offered a quick appointment)."

The promise still stands, but Mr. Cyr said the medical center found that most patients who didn't have urgent needs were interested in scheduling an appointment within a week or so, giving them time to arrange their work or child care schedules.

UMass Memorial has had success so far with the access promise for the majority of patient care needs, but Dr. Cavagnaro said, "The more specialized the doctor is, the longer the wait time."

At Tri-County Medical Associates in Milford, Philip Ciaramicoli Jr., the group's president, said, "We're doing everything we can to meet patient demand by being more efficient."

He said Tri-County added three family practice physicians, one internal medicine specialist and one pediatrician in the past year.

Tri-County nurse practitioners provide some primary care, particularly in pediatrics, and medical assistants have been trained to operate at the highest level of their license.

But in the era of staggering medical education costs, ever-tightening reimbursement and more people seeking access because of health reform and an aging population, the old model of patient care can't continue.

Mr. Ciaramicoli said, "Unless there's a loan relief program or compensation changes, nurse practitioners will be more of the future."

Contact Susan Spencer at susan.spencer@telegram.com. Follow her on Twitter @SusanSpencerTG

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